1, How can I tel if sexual behavior is ormal or abnormal? 2. Who is more likely to engage in these sexual variations—men of women? 3, What is asenuality? Read this chapter to find out, South ageney/Gey Images When Is Sexual Behavior Causes of Sadomasochism Prevention of Sexual Variations Abnormal? Bondage and Discipline Treatment of Sexual Variations Defining Abnormal Dominance and Submission The Normal-Abnormal Continuum Medical Trestments Voyeurism and Exhibitionism Cognitive Behavioral Therapies Fetishism Voyeurism Skills Training Why Do People Develop Fetishes? _Exhibitionism AA‘Type 12-Step Programs What Works? Cross-Dressing Hypersexuality and Asexuality Drag Hypersexuality Female Impersonators Asexuality Transvestites ‘Cybersex Use and Abuse ‘Sadism and Masochism Definitions Sadomasochistic Behavior Other Sexual Variationss~ men love women, some love other men, some love dogs and horses, and Joccasionally you find one who loves his raincoat.” *Max Schulman. (1960). 1 was a Tenge Dwarf New Yor: Bantam Most laypeople, as well as most scientists, have a ten- dency to classify behavior as normal or abnormal. There seems to bea particular tendency to do this with regard to sexual behavior. Many terms are used for abnormal sexual behavior including sexual deviance, perversion, sexual vari ‘ance, and paraphilias. The term sexual variations is used inthis chapter because it is currently favored in scientific circles, Members of the communities who practice these behaviors refer to them as kink In the chapter “Sexual Orientation: Gay, Straight, or 1B?” we argued that homosexuality per seis not an abnor. al form of sexual behavior. This chapter deals with some bebtaviors that more people might consider to be abnor. ‘mal, soit seems advisable a this point to consider exactly when a sexual behavior is abnormal CE When Is Sexual Behavior Abnormal? Defining Abnormal [As we saw in the chapter “Senuality in Perspective,” sex. ual behavior varies greatly from one culture to the next. ‘There isa corresponding variation across cultures in what js considered to be abnormal sexual behavior. Given this sreat variability, how can one come up witha reasonable set of eiteria for what is abnormal? One approach isto use a starsea! definition. Accom ing to this approach, an abnormal sexual behavior is one that is rare, or not practiced by many people. Following this definition, then, standing on one’s hands while having imercourse would be considered abnormal because it is rarely done, although it does not seem very abnormal in other ways. This definition, unfortunately, does not give 1s much insight into the psychological or socal function- ing f the person who engages inthe behavior. In the sociological approach, the problem of culture ependence is explicitly acknowledged. A. sociologist ‘ight define a deviant sexual behavior asa sexual behav- A psychological approach emphasizes the 4Ds of abnormal behavior (Nolen-Hocksema, 2017) (1) dvsfunc tional behavior impairs the person's functioning in daily life; (2) the behavior causes great emotional distress 10 the person: (3) highly devvant behavior (such a hearing voices that no one else can hear, oF desiring sex with a corpse); and (4) behavior that is dangerous to the self oF others (such as commiting sexual assault, which clearly hharms others). For example, a male clerk in a Minneapo- lis supermarket was having intercourse with willing shop- pers in their cars several times a day, This behavior led to his being fired, which is an example of a dysfunctional impairment. The American Psychiatric Association (2013), in its Diagnostic and Statistical Manual of Mental Disorders (DSM-5), uses the terms paraphilia and paraphili disorder. Paraphilia refers to sexual activities other than “vanilla sex”: sexual intercourse (and orl sex, stroking. and so on) with an adult who consents to the activity. Paraphilis, then, are just atypical sexual interests. DSIM-S recognizes eight specific paraphilias: fetishism, transvestism, sexual sadism, sexual masochism, voyeurism, frotteurism, exhi- bitionism, and pedophilia. We consider al of them inthis chapter, with the exception of pedophilia, which is cov- ered in the chapter "Sexual Coercion.” ‘A paraphilia rises to the level of paraphili disorder if it causes the person serious distress or impairs thei func- tioning, or causes harm to the self or others. The impair- ‘ment may be in areas such as relationships with family fr job performance. A happy practitioner of BDSM with other adults who consent to the activity does not qualify as having a paraphilie disorder. The Normal-Abnormal Continuum Each of the approaches just described provides criteria that attempt to distinguish what is normal from what {is abnormal. Although such distinctions may be made in theory, they are often difficult to make in reality For example, lingerie is often sexually arousing for both men ila (parsuh-FILL-2e-uhy ‘Unusual, unconventional sexual behavior and women, For a woman who is wearing a low-cut bra and silk thong panties, the sensuous feel of the material against her skin ‘may be arousing; for a man it ‘might be the sight of the woman jor that violates the norms of society. Thus, if a society says that a particular sexual behavior is deviant, it is-at Jeast in that society. This approach recognizes the impor- tance of the individuals interaction with society and of the problems that people face if their behavior is labeled “deviant” in the culture in which they live. Paraphilc disorder: Parapilia thot causes the person cistress or impairs their tunetioning, or causes har t0 self er athers340 Fetishism: A person's sexval fixation fon some object other than another human being and attachment of reat ‘erotic significance to that object. Streng of preference or fats tet Necessity heist Rap ees Figure 1. The continuum from normal to abnormal behavior in the case of fetishes. wearing the lingerie. At the same time, lingerie is a common sexual fetish object. This isan excellent exam. ple of the continuum from normal to abnormal sexual ‘behavior. That is, normal sexual behavior and abnor: mal sexual behavior-Hike other normal and abnormal Dehaviors-are not two separate categories but rather gradations on continuum. Many people have mild fetishes, finding things such as silk underwear arousing, nd that is well within the range of normal behavior only when the fetish becomes extreme is it abnormal This continuum from normal to abnormal behav- ior might be conceptualized using the scheme shown in Figure 1. A mild preference, or even a strong preference, for the fetish object (say silk panties) is within the normal range of sexual behavior. When the silk panties become necessity-when the man cannot become aroused and have intercourse unless they are present—we have crossed the boundary into abnormal behavior, When the man becomes obsessed with white silk panties and shoplifts them at every opportunity, so that he will always have them available, the fetish has become fetshistic disorder In extreme forms, the silk panties may become a subst tute for a human partner, and the man's sexual behavior consists of masturbating with the sik panties present, In these extreme forms, the man may commit burglary or even assault to pet the desired fetish object. ‘The continuum from normal to abnormal behavior holds for many of the sexual variations discussed in this chapter, such as voyeurism, exh bikionism, and sadism, here) Pg Ce eC EEE Fetishism Fetishism refers toa sexual fixation on some object other than another human being and attachment of great erotic significance to that object. A common fetish inthe United States is for clothing made of leather (Figure 2). Fetishism rises to the level of fetishistic disorder ifthe person is distressed about it (or ifthe fetish causes significant Impairments in their daily functioning. In extreme eases the person is incapable of becoming aroused and having an orgasm unless the fetish object is present. Typicaly the fetish item is something closely associated with the body, such as clothing, ‘An online survey that recruited women at “kink” com: munity events and online forums assessed whether they had ever participated in 126 specific sexual activities (Rehor, 2015). Seventy-five percent ofthe women reported being sexually aroused by an object (a fetish behavior) emg of clothing (sueh as lingerie, shoes, and corsets) and fabri (such as leather, rubber, and vinyl) were the three most frequently mentioned categories of objects. Why Do People Develop Fetishes? Psychologists have proposed different reasons for what ‘causes fetishes to develop. Here we consider two theoret: ical explanations: learning theory and cognitive theory. ‘These theories can be applied equally well to explaining. many of the other sexual variations in this chapter ‘According to learning theory (for example, MeGuire et al, 1965), fetishes result from classical conditioning. in which a learned association is built between the fetish ‘object and sexual arousal and orgasm. In some cases a | oy Figure 2A common fetish is for leather, often in association with sexual sadism and masochism. This store caters to clientele interested or involved In those activities, lion Waser Gey ImagesA Case History of a Shoe Fetishist hae following ease history is taken directly from the 1886 book Psvchopathia Sexuatis, by Richard ‘yon Kraff-Ebing. the great early investigator of sexual deviance. It should give you the flavor of his work Case 114. X, aged twenty-four, Tom a badly tainted fam- ily (mother’s brother and grandfather insane, one sister epileptic, another sister subject to migraine, parents of ‘excitable temperament). During dentition [teething] he hnad convulsions. At the age of seven he was taught to ‘masturbate by servant gr. X. fist experienced pleasure in these manipulations when the girl happened to touch his member {penis} with her shoe-lad foot. Thus, in the predisposed bos, an association was established, a8 a result of which, fom that time on, merely the sight of a ‘woman's shoe, and finally, merely the idea of them, su ficed to induce sexual excitement and erection. He now ‘masturbated while looking at women's shoes or whl cll ing them up in imagination. The shoes ofthe school mis- ‘tress excited him intensely, and in general he was affected by shoes that were partly concealed by female garments ‘One day he could not keep from grasping the teacher's shoes=an act that eaused him great sexual excitement. In spite of punishment he could not keep from performing this act repeatedly. Finally, it was recognized that there ‘must be an abnormal motive in play, and he was sent to ‘4 male teacher. He then revelled in the memory of the ‘hoe scenes with his former school mistress and thus had erections, orgasms, and, after his fourteenth year, ejacu lation, AC the same time, he masturbated while thinking ‘of a woman's shoes. One day the thought came to him to increase his pleasure by using such a shoe for mastur bation, Thereafter he frequently took shoes secretly and ‘used them for that purpose. single learning trial might serve to cement the associay tion. For example, one man recalled, Twas home alone and saw my uncle's new penny loafers. T went over and started smelling the fresh new leather scent and kissing and licking them, It turned me on so much that I actually ejaculated my first load into my pants and have been turned on ever since. (Weinberg al, 1995, p. 22) In this case, shoes were associated with sexual arousal 1s the result of an early learning experience. Another example appears to be the shoe fetishist described in Nothing else in a woman could excite him; the thought of coitus fled him with horror. Men did not imerest him in any way. At the age of eighteen he opened 1 shop and, among other things, deat in ladies’ shoes. He was excited sexually by fitting shoes for his female patrons or by manipulating shoes that eame for mend: ing. One day while doing this he had an epileptic attack, ‘and, soon after, another while practicing onanism in his ‘customary way. Then he recognized forthe first time the {injury to health caused by his sexual practices. He tried to overcome his onanism, sold no more shoes, and strove to free himself from the abnormal association between women's shes and the sexual function. Then frequent pollutions, vith erotic dreams about shoes, occurred. fand the epileptic atacks continued. Though devoid of the slightest feeling for the female sex, he determined on ‘marriage, which seemed to him tobe the only remedy. He married a pretty young lady In site of ively eree- tions when he thought of his wife's shoes, in attempts ‘cohabitation he was absolutely impotent because his dis taste fr coitus and for close intereourse in general was far ‘more powerful than the influence of the shoe/dea, which ‘induced sexual excitement. On account of his impotence the patent applied to Dr. Hammond, who treated his ep Jepsy with bromides and advised him to hang a shoe up ‘over his bed and look at it fixedly during coitus, at the same time imagining his wife to be a shoe. The patient became free from epileptic attacks and potent so that he could have coitus about once a week. His sexual excitation bby women’s shoes also gre less and less Source: Von Krath-Bbing (1886), p. 288 First Person. This case clearly exemplifies the DSM-5 criteria, The youth/man experienced sexual fantasies and urges associated with women’s shoes for years, expe rienced arousal and ejaculation only when they were present, and experienced significant impairment in his academic and social life as a result. There was even an experiment that demonstrated that males could, in the laboratory, be conditioned to become sexually aroused ‘when viewing pictures of shoes (Rachman, 1966). ‘A. second possible theoretical explanation comes from cognitive psychology, discussed in the chapter “Theoretical Perspectives on Sexuality” (Walen & Roth, 3a1342 rag queen: A man wna srossos in women's clothing Female impersonator: A man or woman who impersonates 9 speciic woman a prt of 8 9 Transvestism: The pracice of ceessing 185.0 member of the other gender in order to experiance sexual arousal 1987), According to cognitive theorists, fetishists (or other paraphilies) have a serious cognitive distortion in that they perceive a nonconventional stimulus-such as black leather boots~as erotic. Further, theit perception of arousal is distorted. They feel driven to the sexual behavior when aroused, but the arousal may actually be caused by Feelings of guilt and sei4oathing, Thus there is a chain in which there are initial feelings of guilt at thoughts of the unconventional behavior, which produces arousal, which is misinterpreted as sexual arousal (see misattribution of arousal in the chapter “Attraction. Love, and Communica- tion"), which leads toa feling thatthe fetish ritual must be carried out; itis, and there are orgasm and temporary feelings of relief, but the evaluation ofthe event is negative, leading to further feetings of guilt and selFtoathing, which perpetuates the chain Whatever the cause, fetishism typically develops early in life. In one sample of foot or shoe fetishists, the mean age at which respondents reported first being sex- ually aroused by feet or shoes was 12 years (Weinberg etal. 1995). EEE Cross-Dressing Crossaressing refers to dressing as a member of the other gender. Crossdressing may be done by a variety of people for a varity of reasons (see Figure 3). Trans men typically dress a8 men as part of their transition (transgender expe- riences are discussed inthe chapter “Gender and Sexual ity”), Here we discuss three other types of crossdressing: rag, female impersonation, and transvestism, Drag Some gay men—drag queens-dress up as women, and some lesbians dress in masculine clothes (drag kings) (Moncrieff & Lienard, 2017). These practices are basically caricatures ‘of traditional gender roles and are usually done ina playful way, asa performance. ‘Currently, perhaps the most visible example of drag in our culture isthe television series RuPaul's Drag Race (see Figure 3). Female Impersonators Female impersonators are_men ‘who dress as women, often as part, of their job as entertainers. For example, Robin Wiliams as Mrs Doubifire and Dustin Hoffman a8 Tootsie won praise from erties and big box office profits for their impersonations of women. Figure 3 _RuPaul’s Drag Race All Stars attending the 2016 MTV Video Music Awards, Madison Square Garden, New York. Derbi Van Tie/ riser Fotos pctareoliance/dpa/AP Images Transvestism In contrast 10 people who engage in crossdressing for the reasons discussed above, some men regularly dress in Female clothing to produce sexual arousal and experience sexual excitement. Ths practice is known as transvestism. ‘The crosedressing is often done in private, perhaps by & married man without his wie’s knowledge, Crossdressing is almost exclusively a male. sexual variation: it i essentially unknown among women, There may be a number of reasons for this difference, including four culture's tolerance of women who wear ‘masculine clothing and intolerance of men who wear feminine clothing. Also, trad tionally, women's clothing is by design sexual and erotic, whereas men’s clothing is functional (Wheeler et a, 2008). ‘The phenomenon illustrates a more general point, namely, that many sexual variations are defined for, or practiced almost exclusively by, members of one gender; the paral lel practice by members of the other gender is often not ‘considered deviant. Most sexual variations are practiced mainly by men. ‘A survey of a national sample in Sweden asked each participant whether they had ever dressed in clothing of the other gender and experienced sexual arousal (Lng- str & Zucker, 2008), Almost 3 percent of men and 0.4 percent of women reported at least one such experience. In one sample of transvestites, 87 percent were hetero- sexual and 60 percent were married; 66 percent reported that ther first crossdressing experience occurred before age 10 (Docter & Prince, 1997). Sexual excitement and rere cian PevtRaeins‘orgasm were reported by 40 percent as frequently occur. ring with crossdressing. Almost all prefered dressing ‘completely as women during the activity, but only 14 percent frequently went out in public dressed as women How do the wife and children ofthe crossdresser react {to his unusual behavior? One researcher observed four stages in the process (Lev, 2004). The fist is discovery or disclosure, in which the wife discovers her husband's cross-dressing or he discloses it to her. The next stage is ‘marked by turmoil, both in the relationship and for the individual. In the third stage, the couple negotiate: what is acceptable? What are the boundaries? If all ofthis goes suecessully, the couple enter the fourth stage, finding @ new balance. One study of wives of crossdressers-the hnusbands were either transvestites or trans women—found ‘many ways in which the stories of these relationships unfolded (Erhardt, 2007). For example, in one ease, Joe (names are changed to preserve anonymity) told Kate about his crossdressing by phone while he was out of town. Kate had a strong emotional reaction, even consid ering suicide, but instead of making a snap decision to leave Joe, she sought both individual and couple counsel ing. As a result, she set clear limits; for example, he could crossdress only while he was away on business trips. ‘Their relationship did indeed find a new balance. ‘Occasional crossdressing is one of the harmless, vie timless sexual variations, particularly when it is done in private. Like other forms of atypical behavior, i isa prob: Jem only when it becomes so extreme that iis the person's only source of erotic gratification, or when it becomes @ ‘compulsion the person cannot control and it therefore ‘causes distress in other areas ofthe person’ life eco Sadism and Masochism Definitions A sexual sadist is a person who experiences intense sex- ual arousal from the physical or psychological suffering of| another person. The term sadism derives from the name ‘of the Marquis de Sade, who lived around the time of the themselves, but these are not the meanings used here. These * two are often referred to as. pair because the two behaviors ‘or roles (giving and receiving pain) are complementary. ‘There are two other styles of interaction that are related to sadismmasochism (S-M). These are bondage and disc pline (BLD) and dominance and submission (D-S) (Ernult & Innala, 1995). Bondage and discipline refers tothe use of physically restraining devices or psychologically restrai ing commands as a central aspect of sexual interactions. ‘These devices or commands may enforce obedience and. servitude without inducing any physical pain, Dominance and submission refers to interaction that involves a conser sual exchange of power; the dominant partner uses their power to control and sexually stimulate the submissive partner. In many cases, all of these sexual practices are srouped together under the term BDSM. ‘Sadomasochistic Behavior ‘Sadomasochism (SM) is a rare form of sexual behavior. 'A review of the literature found, among men evaluated for paraphili disorders, 3 to II percent were diagnosed as sadists, and 2 to 6 percent as masochists (Krueger, 2010), In its milder, nonparaphilic, forms it is probably more ‘common than many people think. A survey ofthe general population found that 2.2 percent of men and 1.3 pereent ‘of women reported involvement in BDSM in the past year (Richters etal, 2008). Sadistic or masochistic fantasies appear to be considerably more common than reallife ssadomasochistic behavior. ‘An online survey of women recruited through the “kink ‘community included 62 “BDSM-elated” behaviors (Rehor, 2015). Many participants (75 to 85 percent) reported behay- Jos that cause pain, including breast play (slap, clothespins), paddling, flogging, genital ply (slap, kick, elothespins), and ‘whipping and caning. The use of bondage toys for sensual or erotic pleasure was reported by 85 percent as Wel ‘A.good example of BDSM activity is Strictly Spanking party in New York City (David, 2011). These bimonthiy parties attract men and women who like tobe spanked, and spankings are the main activity People wear colored nametags not ing whether they are atop. abot. | Servet sd & person who expe, ‘tom, oF switch, At one party, most | [ences intense sex arousal the suffering of another person. ‘of the participants were over 45, | Sexual masochist: A porson who and ordinaryooking people from | experiences tense sexual arousal many walks of life, Most were | ffom being besten, bound, humt- straight. Spankos talk about being ated, oF mace to suffer. fascinated by spanking from a | Bondage and aieciptine: The use of young age. People do not pair physical or psychological restraint to off and have sex during ot after teforce servitude, from which both the party. For a few participants, Participants derive sensual pleasure. Dominance and submission: The spanking becomes a central focus oftheir lives; they cultivate daddy. use of power consensually given to daughter relationships, and may French Revolution. Not only did he practice sadism—sev- «eral women apparent died from his atentions (Bullough, 1976)-but he also wrote novels about these practices (the best known is Justine), thus ensuring his place in history. ‘A sexual masochist isa person who experiences intense sexual arousal from fantasies or the behavior of being humiliated, beaten, bound, or otherwise made to suffer. ‘This variation is named afer Leopold von SacherMasoch (1836-1895), who was himself a masochist and who wrote novels expressing masochistic fantasies. Notice thatthe deft nitions of sadism and masochism make specific thei sexual nature; the terms are offen loosely used to refer to people ‘who are cruel or to people who seem to bring misfortune on contol the sexual stimulation and behavior ofthe other person,PTR Siem amet ascetic Sexual Addictions? einem aeons J acs corte nan) akon having at eee "8a ae See aa a aeer ok SETS Be eae ee eerie tht hs aes” Ste enue sv ste snow ashamed of, Eventually she “hit rock bottom” and read ‘a pamphlet with questions like “Have you had sex at inap- Seat eee re ede ea Fore palr aneeael aU pen es oe Cred soporte fsx dct 200, pA as ping eat Pie Wrens aad Wey eee Sa (0 as Maks es honed SoBe ad (Sac a ates ST a ch Waka Hie lt “CAL Se lng eae ere VR eee td hed pwn 2 ys fom online: Sea ey ler etre apt eaten! progam fo 5 adc" (DenzerLen 200), ese ak fas opr ik iS ths th Und Sie, The al Sa be sone ctr o is panilee eiet Sel ely ens deseo rng he Sl Seley eciacee Wome ea ac tof focal fincerng Inhale, Bit ted of Citing phat ee wh gue pupil tune ener eeraL yee ape Pati Canes (1983 nis tok The Se Ain eee ts eee err cara ea the ret fan adie process ch esto. Prati tefnty bet Sens ad ello ray harris of alata: Pa ste re coe uprnce(condmt) beatae thug hs ta Jit Um to red sts de” Us ced its on eto mys etc beter necordg to Cares tas ch eas ofthe scaly uote beer pczes though ort Set wich neste ech net spewed 1. Preoecupation. The person can think of nothing other than the sexual act to which they are addicted. 2. Rituals. The person enacts certain rituals that have become a prelude tothe addictive act, 3. Compulsive sexual behavior. The sexual behavior is enacted and the person fels that they have no control over it 4. Despair, Rather than feeling good after the sexual act is completed, the addict falls into a feeling of hnopelessness and despair Carnes recognizes the distinction between a sexual ‘behavior and a sexual behavior that is out of control and ‘dysfunctional. Thus, for example, the man who mastur- bates while looking at pornographic magazines two or three mes per week is not an addict, and the behavior is ‘well within the normal range. However, the man who buys 20 porn magazines a week, masturbates four or five times 4 day while looking at them, for a total of perhaps two or three hours, and can think of nothing else but where hhe can buy the next porn magazine and find the next pri vate place to masturbate—that person is addicted. The key {s the compulsiveness, the lack of control, the obsession (constant thoughts of the sexual scenario), and the obvi fousness to danger or harmful consequences, Accorng to Carnes and others, the most effective ther apy for the sex addict i the Aleoholies Anonymous program applied to sexual addictions. Several groups have adapted the AA program to sexual addiction, among them Sexahol ies Anonymous (SA), Sex Addiets Anonymous (SAA), and Sex and Love Addicts Anonymous (SLAA). These groups ‘can usualy be found by searching the Internet; each group ‘nasa national website with an app for quickly finding local ‘meetings. The fist step inthe process of recovery is admit- ting that one is sexually addicted, thatthe behavior is out of control, and that one's life has become unmanageable. ‘These are hard admissions to make for someone who has spent years denying the existence of a problem. There are frequent meetings with a support group, an emphasis on recognizing the ways in which the behavior has impaired your life and relationships, and a strong emphasis on deal ing with shame and building feelings of sel worth. “The concepts of sexual addiction and therapy as the treatment for addiction have been widely adopted, Media and laypeople casually label persons whose sexual activity ‘seems bizarre (remember our discussion of the subjective nature of this word?) “addicts.” The term is frequently used when highprofile celebrities behave badly in the sexual arena. In addition to thousands of support groups,there are dozens of in-patient facilites waiting to weleome the “addict” into “tecovery.” The support groups are fee; the in-patient treatment is really expensive. The concept of addiction has been used in many socioegal contexts as & defense against charges of sexual misconduct (the anesthe siologist who fondled his female patients while they were sedated) of as a charge in divorce cases to get custody of the children (he frequents prostitutes) (Ley eta, 2015). Other criticisms have come from therapists and researchers in the fleld, The term addiction, as to alcohol fr heroin, has a very specific definition among profes sionals, and sexual addictions do not meet the definition in some ways. For example, if one is addicted to alcohol and suddenly stops using it, there isa withdrawal phenom: ‘enon that involves unmistakable physical symptoms. If « person abstains from an addictive sexual behavior, there are no physiological withdrawal symptoms. A second crit- ‘cis is that “addiction” may become an excuse for illegal, ‘destructive behavior. For example, a rapist might say, “I'm ‘addicted to violent, nonconsensual sex and therefore can't stop myself.” Cities of the addiction mode! have suggested several alternatives. One is based on the coneept of compulsive ‘sexual behavior (eg, Coleman, 1991). Compulsive sexual behavior (CSB) {s a disorder in which the individual experiences intense sexually arousing fantasies, urges, and associated sexual ‘behaviors that are intrusive, driven, and repetitive. Ind- viduals with tis disorder are (a) lacking in impulse con- ‘nol, (b) often incur social and legal sanctions, (c) cause interference in interpersonal and occupational function- ing and (a) create health risks. (Coleman et a, 2001, 326) Sexually compulsive individuals experience intrusive sexual thoughts, and they engage in out-of-control sex- ual behavior to reduce anxiety, depression, and shame live together. Spanking is also an activity that may be part of disciplinary or bondage scenes, but it has a different ‘meaning in those setings. Thus there is a spectrum of activities that constitute ‘SM. People who become involved in it often have tried a variety of these behaviors and find only some of them sat- {sfying. They develop a script of activities (recall the com ‘cept of scripts in the chapter "Theoretical Perspectives on Sexuality”) that they prefer to enact each time they engage in SM, One group of researchers identified 29 individ- ual sexual behaviors associated with SM (Santi etal 2002). Four clusters or themes were identified: hypermas- eulinity (eg. dildo, enema), administering and receiving pain (eg, elothespins attached to nipples, caning, hot “(Rooney et al, 2018). Research shows that, indeed, sex- ual compulsivity is correlated with depression and anxiety (Rooney et al, 2018). Across various studies, the prevalence of sexual compu ‘Sivity ranges between I and 6 pereent of the U.S. population ‘(Krause a, 2018). About haf of those with sexual compu sivity report that it began before age 18 (Reid et al, 2012). One crucial criterion for a sexual behavior 10 be considered abnormal is that it ereates. impairment in the person's daily functioning. People who are sexually compulsive report many kinds of impairment, including negative impacts on mental health, emotionally hurting 4 loved one, interference with the ability to experience ‘healthy sex, and even loss oftheir job (Reid eta, 2012), In regard to status asa diagnosis, neither sexual addic- tion nor compulsive sexual behavior is a recognized ‘diagnosis in the DSM-S. Obsessivecompulsive behavior is. Compulsive sexual behavior has been proposed for Jnclusion in the ICD+I1 (the ICD being the alternative to the DSM for diagnoses); it would be categorized as an impulse-control disorder (Kraus etal, 2018), ‘Regardless of offical status asa diagnosis, some peo- pile believe that they have a sexual addiction and seek ther- apy for it (Wéry et al, 2016). In one sample of people seeking treatment for sexual addiction, 94 percent were ‘men (Wéry etal, 2016). Common patterns involved sex ‘with multiple partners and eybersex. Sexual compulsivity Js in some ways similar 10 hypersexuality. Some ‘experts say that the two are overlapping. yet ise tinct Rooney etal, 2018). Other experts use the terms interchangeably. Compulsive sexual behavior (CSB): ‘A isorde in which the individual ‘experiences intense sexually ‘rousing fantasies, uges, and tessoclated sexual behaviors that ‘ore out of convo and interfere with dally functioning wax), physical restriction (e., handel, straitjackets), and humiliation (e.., verbal humiliation, face slspping). Further analyses of the participation in the behaviors within each cluster identified a continuum in frequency from very common to very rare, with the order of the ‘behaviors susgesting that this continuum reflects a dimen- sion from least to most intense. For example, the humili- ation continuum ranges from flagellation (reported by 81 percent; least intense) to verbal humiliation (70 percent), ‘tagging (53 percent), and face slapping (37 percent) to using knives to make surface wounds (11 percent; most intense). The results suggest thatthe SM activities within each cluster are scripted, with the less intense behaviors being much more common,Some observers note that $M is about play, asin the theater. SM sexual activities are organized into "scene®”; ‘one “plays” with one’s S-M partners. In addition to the activites such as those discussed above, roles, costumes, and props are important parts of each seene, The roles ‘nelude slave and master, maid and mistress, and teacher and pupil. The costumes range from simple to elaborate The props may include tight leather clothing, pins and needles, ropes, whips, and hot wax. In SM clubs there are often rules governing the social and $M interaction, pac: ticularly the eeation and enactment of scenes, Rules may include no touching of another's body without consent. siving players the room they need to enact a scene, and ‘ot intruding physically or verbally on a scene in progress; and they may include no sexual penetration. Interestingly, sexual sadists and masochists donot com- sistently ind experiencing pain and giving pain to be sex ually satisfying. For example, the masochist who smashes 4 finger in @ car door will yell and be unhappy just like anyone else. Pain is arousing for such people only when it is part of a carefully scripted ritual. As one woman put it ‘Of course, he doesn't weal hurt me. mean quite recently he tied me down ready to receive “punishment.” and then by mistake he kicked my heel with his toe ashe walked by. I gave a yelp, and he stid, “Sorry love-did I hurt you?” (Gosselin & Wilson, 1980, p. 55) Causes of Sadomasochism ‘The causes of sadism and masochism are not precisely knowin, The theories discussed in the section on fetishes can be applied here as well. For example, learning theory points to conditioning as an explanation, A litle boy is being spanked over his mother’s knee; in the process, his penis rubs against her knee, and he gets an erection. Or a litte gin is caught masturbating and is spanked. In both ‘eases, the cilld has learned to associate pain or spanking with sexual arousal, possibly setting up a lifelong career as ‘a masochist. ‘Another psychological theory has been proposed 10 explain masochism speeifialy although not sadism (Bau: meister, 1988a, b). According to the theory, the masock. ist is motivated by a desire to escape from seltawareness. That is, the masochistic behavior helps the individual escape from being conscious of the self in the same way that drunkenness and some forms of meditation do. In an era dominated by individualism and selfinterest, why would anyone want to escape from the self? Probably because high levels of selfawareness can lead 10 anxiety as 4 result ofa focus on pressures on the self, added respon- sibilities, the need to keep up a good image in front of ‘others, and so on. Masochistic activity allows the person to escape from being an autonomous, separate individual Masochism may be an unusually powerful form of escape ‘because ofits link to sexual pleasure. This theory can also explain why patterns of masochism seem to be so gender linked (Baumeister, 1988b). According to the theory, the male role is especially burdensome because of the heavy Pressures for autonomy, separateness, and individual achievement. Masochism accomplishes an escape from these aspects ofthe male role, explaining why masochism is more common among males than among females. Bondage and Discipline ‘Sexual bondage, the use for sexual arousal of restraining devices that have sexual significance, has been a staple of erotic fltion and art for centuries. Current mainstream ‘and adult films and videos portray this activity. In some communities, individuals interested in B-D have formed clubs (Figure 4). ‘We noted earlier the difficulty of gathering data on participation in variant forms of sexual expression. One Jnnovative study downloaded all the messages about bond: ‘age mailed to an international computer discussion group (Eroulf & Innala, 1995), OF the messages in which send- ers indicated their gender, 75 percent were male. OF those indicating a sexual orientation, most were heterosexual: 18 Percent said they were gay, 11 percent lesbian. The mes sages were coded for discussion of what the person found sexually arousing about B.D. Most frequently mentioned (12 percent) was play: “Sex is funny, and sex i lovely, and sex is PLAY.” Next was the exchange of power (4 percent): “Its a power trp because the active is responsible forthe submissive’s pleasure.” The next most common themes were intensifed sexual pleasure, tactile stimulation associ ated with the use of ropes and cuffs, andthe visual enjoy: ‘ment experienced by the dominant person. ‘There is a marked imbalance in preferences for the ‘active (“top”) and passive (bottom) roles. Most men and ‘women, regardless of their sexual orientation, prefer to be “bottom.” This may be the reason there are an estimated 2,500 professional dominatrices inthe United States, Dominance and Submission Sociologists emphasize that the key to SM is not pain but rather dominance and submission (D-S) (Weinberg, 1987), Thus it is not an individual phenomenon but rather social behavior embedded ina subculture and controlled by elaborate scripts, Sociologists believe that to understand D'S one must understand the social processes that create and sustain it (Weinberg, 1987). There is a distinet DS subculture, involving videos, clubs, and bars, It creates culturally defined meanings for D'S acts. Thus a D'S act i nota wild ‘outbreak of violence but instead a carefully controlled per: formance with a serip. One woman reported that ‘we got into dominance and submission. Like him giving me orders. Being very ough and pushing me around andvores aN BesONSH 347 Figure 4 Sexual bondage involves restraining devices and discipline, such ‘9s in this scene tiving me orders, calling me a slut, calling me a cunt Making me erawl around ...on all ours and bee to suck his cock, Dominancesubmission is more important than the pain, Ive done lots and lots of scenes that involve ro pain, Justa lot of taking orders, being humiliated (Maurer, 1994, pp. 253, 257) Within the play, people take on roles such as master or naughty child. Thus American men can play the submissive role in D>S eulture, even though it contradicts 1 USS, male role, because itis really not they who are play the part of a murderer and know that he i not a murderer One interesting phenomenon, the naughty child, just as an actor ca from a sociologica i the social control over risktaki Weinberg, 1987). Thi strained and point of view, exists in the DS subeultu is, having allowed oneself to be tied up of then whipped, one could be seriously injured or even mur rare, Why? Research shows to luce the risk and ensure that the play is “sa, sane, and ents are made in ord that complex social arrangen consensual” (Holt, 2016). Fist, initial contacts are usu ally made in protected territories such as bars or meet ings, which are inhabited by other D-Sers who play by th same rules. Second, the basic scripts are widely shared, s that everyone understands what will and will not occur. ‘When the participants are strangers, the scenario may be negotiated before itis enacted. If an individual violates a boundary, the violation is typically handled within the BDSM community by appointed community members (Holt, 2016) FC Voyeurism and Exhibitionism Voyeurism and exhibitionism ae often discussed together because the ather different, and a voyeur would not find watching an exhibitionist arousin seem complementary. However, they are Voyeurism A rayeur is & person who experi an unsuspecting person who is naked, inthe process of undressing, or engaging in Sextal omes a paraphilia when it is man. ifested b behaviors (DSM, 302.82 2013), Voyeurs ate often feferred to as “peeping toms Tn one national sample from Canada, 50 percent of men arousal from watching and 21 percent of women had engaged in voyeurism at least once in thet lifetime (Joyal & Carpenter, 2017) Voyeutisen pr ides another good. illustration of the continaum from norn al to abnormal behavior. For find it arousing to wateh a man | Voyeur A person who experiences cor woman undress and “dance | £®al arousal om viewing unsus: otherwise, there would be no strip clubs-and this is certainly well shed excep ne, Tom348 Exhibitionist: person whe derives qi Figure 5a Exhibitionism. Within the normal range of behavior. Some women are crotch watchers,” much as men are breast watchers The appeal of watching sillustated bya study of college students that asked whether they would watch an attractive person undress and an attractive couple having sex (Rye & Meaney, 2007). Two-thirds said they would watch someone undress: 45 percent said they would watch the eouple A study of men who sought treatment for paraphilias cluded 62 voyeurs (Abel & Rouleau, 1990), Onethird reported that their first experience occurred before they were 12 years old, Onehalf said they recognized their interest in peeping pri that, on average, they had This study, howeve to age 15. These men estimated sd at 470 people Points out one of the major probe Jems withthe research on sexual variations: Much of thas ed for their been done only on people who have been arr behavior analyst suggests that only «smal minority of “peepers” are distressed by their behavior (Lavin, 2008) The “respectable paraphiliac™ who Figure 5b High-rise hotels and apartment buildings provide a new venue for exposing one's body to strangers. has the behavior under somewhat better contro or who is skilled enough or can pull enough strings not to get caught is ‘not studied in such research, Thus the pictute that research provides for us of these variations may be very biased Exhibitionism The complement to voyeurism is exhibitionism ("fash in”, in which the person derives sexual pleasure from exposing his genitals to @ nonconsenting person.’ The pronoun “his” is used advisedly, because exhibitionists are usually men. The woman who wears a dress that reveals most of her bosom is likely 1o be thought of as attractive wer than abnormal, When a man exposes himself, hw his behavior is considered offensive (Figure Sa) There was a young indy of Exeter So prety men eaned their necks the.Here again, whether a sexual behavior is considered abnormal depends greatly on whether the person doing isa male or a female. (Recall our discussion ofthe social constructionist view of paraphilias and gender.) A man exposing himself to @ man is also quite rare, so the proto- ype we have for exhibitionism is a man exposing himselt toa woman. One study of sex offenders in federal prisons found that about 20 percent of them had engaged in exhi- bitionism (Drury eal, 2017). A wellsampled study of the Finnish population found that 4 percent of the men and (046 percent of the women had engaged in exhibitionism (Baur etal, 2016). ‘According to the benchmark study of men seeking ‘treatment for paraphilias (Abel & Rouleau, 1990), 15 per- cent of the exhibitionists had exposed themselves atleast ‘once by age 12; onehall had done so by age 15. Research ‘with exhibitionists and other sex offenders who had been arrested for their behavior showed that they were likely to have experienced adverse events in childhood, such as father abandonment and physical or emotional abuse (Drury etal, 2017), Many women, understandably, are alarmed by exhibi- tionists, But since the exhibitionis’s goal is to produce shock oF some other strong emotional response, the woman who becomes extremely upset is gratifying him. Probably the best strategy for a woman to use inthis situ- ation isto remain calm and make some remark indicating her cooiness, such as suggesting that he should seek pro- fessional help for his problem. Notice that both voyeurism and exhibitionism are considered problematic behavior when the other person involved is an unwilling participant. A man who derives erotic pleasure from watching his partner undress, ot a woman who is aroused by exhibiting her body in new lin- etic to her husband, is not engaging in eriminal or para- philic behavior. Hypersexuality and Asexuality We turn now to several variations that are not explicit listed in the DSIV-5; however, each ofthese may vary from atypical to paraphilie, depending on ther frequency, dura ‘other concerns and interests. When it occurs in women, “itis called nymphomania; in men it is called satriasis (or Don Juanism).* Although this definition seems fairly sim- ple, in practice itis difficult to say when a person has an abnormally high sex drive. As was discussed in the two chapters on “Sexuality and the Life Cyele,” there isa wide range in the frequencies with which people engage in coitus: therefore, the range we define as “normal” should also be broad. In real life, mimphomania or satyriasis is often defined by the spouse. Some men, for example, ‘might think that it was unreasonable for a wife to want intercourse once a day or even twice a week, and they ‘would consider such a woman a nymphomaniae.® Other men might think it would be wonderful to be married to 8 ‘woman who wanted to make love every day. Because these two terms are imprecise, clinicians and researchers prefer the term hypersexually. Hypersexuality refers to an excessive, insatiable sex drive in a person. It leads to compulsive sexual behavior in the sense that the person feels driven to it even when there may be very negative congequences. The person is also never satis fied by the activity, and they may not be having orgasms, despite all the sexual activity. Such cases meet the criteria for abnormal behavior discussed at the beginning of this chapter: The outofcontrol behavior and the time it eon- sumes leads to the result that it impairs the functioning in other areas ofthe person's life (Kafka, 2010), ‘A study of male patients with paraphilia or related disorders focused on creating an operational definition of hypersexuality (Kafka, 1997). The results supported the use of the eriterion of seven or more orgasms per week consistent, for @ minimum duration of 6 months. The ‘men reported an average of 8 orgasms per week in the pre- ceding 6 months; the modal time per day the men spent in unconventional sexual activity was 1 to 2 hours. The ‘most common unconventional behaviors were compulsive ‘masturbation (67 percent of the sample), protracted pro- miseuity (56 percent), and dependence on pornography (41 percent), The most common paraphilias were exhibi tionism (35 percent of those with a paraphilia), voyeur ism (27 percent), and pedophilia (25 percent) This research provides a useful operational definition for_men, Nymphomania (nim-foh-MANE- in excessive, insatiable sex ‘eve ina woman, 349 tion, and consequences, but note that the suggested erite- rion cannot be applied to women. ‘The erterion is stated as the num- ‘Satyriasis(sat-urEYE-ubsis): An ‘excessive, Insatiable sex ve in 2 ‘man; aso cated Don Juans. Hypersexuality Hyperseruality includes nymphomania and satyriasis, Conditions in which there is an extraordinarily high level cof sexual aetivity and sex drive; at the extreme, the per son is apparently insatiable and sexuality overshadows all ‘ashe the pt attendant atthe sizport she replied “I want to ee your boarding pass, ot your stu beer of orgasms per week. Some | M¥Persexualty: An excess ‘women rarely or never experience = “Saris is narod forthe sts, who were prthunan,prtanial beans in Grek mythology part ofthe entourage of Dionysus the od of wine and frit, they Were ova and sty and have Become 2 symbol ofthe sexually active male "someone once defined a nymphomaniac asa women whom a man cant keep up with Hypersenualty An excessive, nss-350 Figure 6 Histo man has an excessive, insatiable sex drive. sms; in fact, their anorgasmia might cause them to engage in compulsive sexual behavior. Another problem © capable orgasmic of multi ter “Sexual Arousal"), A woman who engages in sextal activity three times a week could experience seven or eight orgasms, which would not be atypi¢al or abnormal Once again we see that a person’s gender is very import ant in defining sexual variations. A central debate among experts is whether hypersexu ality is truly a disorder, or simply a medically constructed label for someone with high desire (in and of itself, not a disorder), Researchers posted an online survey contain: ing measures of sexual desire, sexual activity, perceived control over one’s sexuality, and a variety of potential negative outcomes (Carvalho et al, 2013). Over 4,500 men and women ages 18 10 60 completed the survey, The data were enalyzed using cluster analysis, which identities The analyses identified two clusters, one reflecting prob lematie sexualitylack of control and experie ative outcomes, and the other reflecting high desire and frequent activity. Comparing people in the two clusters on other variables, individuals in the hypersexuality clus ter reported more psychopathology. Thus, hypersexuality properly defined/measured appears to be distinet from high desire. Researchers have developed a scale to assess hyper sexuality, the Hypersexuality Behavior Inventory 0 HBI (Reid et al, 2011), The scale inclu respondents to report the relative frequency of ical painting of a satyr, which gives the name to satyriasis, a sexual variation in which a a variety of experiences related to sexuality during the ‘past 90 days, The seale was validated using two samples of male outpatients drawn from several stats, including ‘men reporting compulsive masturbation, habitual solic tation of commercial sex workers, extramarital affairs, sated land multiple anonymous partners. Analyses indi three characteristics of hypersexuality: lack of control (My attempts to change my sexual behavior fui"), con: re with... work Ito} deal with my sequences (“My sexual activities of school”), and coping ("I use sex problems”) A study of hypersexuality in women used data from an online survey that included the HBI and measures f present and past sexual activity (Klein et al, 2014). High-scoring women on the HBI reported significantly more frequent consumption of porno 30 times per month) and masturbation (more than 6 raphy (more than imes per week). The researchers concluded that hyper sexuality in women is associated with impersonal sextal activity Online surveys give us some idea of the prevalence lf behaviors among people in « population. Presumably ‘many of those wh on a measure ike the atain high oor HBI are not experiencing significant impairments in their daily lives. An alternative approach isto examine the char acteristics of those who seek treatment fora condition or disorder. The Sexual Behavior Clinic in Toronto sees a large number of patients every year. Researchers reviewed referrals and consultation requests for “hypersexually 1013) and identified six types. About one third of the people philic Hypersexualityextremely high frequencies of behaviors such as pornos raphy consumption or very frequent solicitation of paid partners, and various additional paraphilic interests (fetishes, voyeurism, etc.). A second type was Avoidant Masturbation, men who spend a great deal of time view- ‘ng pornography and several hours per day masturbating, ‘often leading to schoo! failure, job loss, or socal isolation. AA third type, and the one most frequently publicized in the media, is Chronie Adultery, people who chronically ‘cheat on spouses, but have few paraphilic interests and ‘do not spend large amounts of time pursuing sexual grat- ification. Men in this category often report a desire for daily sex, and that sex with their wives is infrequent or does not occur, due to her dyspareunia, very low libido, or past sexual abuse. The fourth type is Sexual Guilt, men and women whose sexual activity is within the normal range but they feel extremely guilty about it, People in this group are often selfreferals, and more likely to be female. The ith type is the Designated Patient, someone referred by their romantic partner; the partner has very restrictive beliefs about sex and discovers some activity by the patient that they disapprove of. The patient shows ‘no signs of behavioral extremes/paraphilic disorder. The last type is the person who is diagnosed as exhibiting @ snonsexual conditionpersonality disorders, hypomania, ‘or developmental delays. Sometimes their symptoms are related to medications they are taking. Notice that peo- ple in three of these categories are not exhibiting signs of atypical or disordered sexuality, reminding us that we need to be very careful when applying diagnostic labels (such as hypersexuality) to people. Asexuality sexuality is defined as having no sexual attraction 10 another person. Researchers used data from the National Survey of Family Growth to esti- ‘mate the prevalence of asexuality in the United States (Poston & Baume, 2010). Responses to ‘questions were used to con: struct three indices of sexuality assessing behavior, identity, and sexe ual attraction; 0.6 percent ofthe females and 0.9 percent ‘of the males gave the asexual response to all three. A sim- ilar survey in New Zealand found that 0.4 percent of the sample identified as asexual (Greaves et al, 2017). Com- pared with heterosexuals, the asexuals were more likely to bbe women, less likely to be cisgender, and less likely to be in serious romantic relationship. ‘A critical controversy concerns whether asexualty is 1 sexual orientation, a sexual dysfunction (as described in the chapter "Sexual Disorders and Sex Therapy”), a symptom of a mental disorder, or a paraphilia (Brotto & Yule, 2017). Experts have generally rejected the idea that asexuality is «symptom of a mental disorder, asexuals, for * example, have the same rates of depression as the rest of the population, With regard tothe possibilty that it might bbe a sexual dysfunction, asexuality might be an arousal disorder or a sexual desire disorder. Research, however, shows that selfidentified asexual women show the same genital response to erotic flms, assessed by a photoplethys mograph, as heterosexual and lesbian women. Asexuality might be a desire disorder representing extreme lack of | desire. However, people with low sexual deste disorder are distressed with their lack of desire, whereas asex als are fine with their lack of sexual attraction to others. Moreover, asexuals masturbate. They just aren't interested in sex with other people. As forthe paraphilia hypothesis, paraphilias ae atypical sexual interests; is lek of interest in anyone therefore a paraphilia? Some experts have con- cluded that asexuality should count as a sexual orienta- tion (Brotto & Yule, 2017) If sexual orientation refers to attraction to members of one’s own gender, members of the other gender, or both, shoukin’ attraction to neither also be an ofientation? Se Cybersex Use and Abuse Researchers have identified a long list of online sexual activities (OSA) that people engage in (Shaughnessy eta, 2017). The activities are grouped into three broad categories: © Nonarousal OSA: Examples include looking for sex {information online: looking for advice online about sexual relationships; joining an online dating service; and joining an online kink community "= Solitaryarousal OSA; Examples include viewing sexually explicit pictures or videos; watching others engaged in sex on a webcam; and posting a video of yourself engaging in sex, Partnered.arousal OSA: Examples include having. ‘your avatar engage in sexual activity with another ava- ‘ar; participating in an online sexual chat for sexual ‘arousal; using an electronic sex toy that is controlled through the Internet by someone else (e.g, with the aor); and engaging in sexual ats by yourself, that ‘someone on IM was telling you todo for a webcam. The possibilities are endless ‘One study surveyed college students in four nations (Canada, Germany, Sweden, and the United States) about their OSA (Daring et al, 2017). Overall, 90 percent had accessed sexual information online, 31 per cent had engaged in cybersex, and sexuality: nck of sexual 351352 oaprta ot» vaanons nSPxual aOR 1 percent had paid for online sexual services. Patterns looked the same in all our countries, testifying to the slobal reach of the Internet-at least in more affluent nations, ‘A major concern in recent years has been whether the tse of the Internet to access sexually explicit materials, chat rooms, and bulletin boards can become compulsive ‘or paraphilc. This concern has been raised by therapists and clinicians, who report cases of Internet use leading to job loss, relationship difficulties or divorce, and other adverse consequences (Galbreath etal, 2002), “The Internet is thought to be especially likely to lead to ‘compulsive behavior beeause iis characterized by the three As: anonymity, accessibility, and affordability you arent oot. Unlike facetoface behaviors such as eruising for a partner, Internet users are anonymous. The Internet is avail able 24/7, and its use is relatively cheap-you can download almost any kind of sexual material, sometimes for free. Internet “abuse” has been variously characterized as paraphilic, compulsive, or addictive. As noted ear lier, intense and persistent use of the Internet in ways that significantly impair daily life or cause distress ‘may constitute hypersexuality. The research review: ing referrals to the Sexual Behavior Center identified extremely high frequencies of pornography consump: tion as Paraphilic Hypersexuality. Men who spend a great deal of time viewing pornography and several hhours per day masturbating were identified as a sec- fond group within the hypersexual category. Yet it is likely that only a small number of people access sexu- ally explicit materials in ways that fit the definition of 1 paraphilic disorder. What about pornography use as compulsive behan- tor? Research using a sexual compulsivity seale sought to determine what percentage of users were compulsive users (Cooper etal, 2000). The study found that 83 percent of the participants were not problematic users. Eleven per ‘cent attained moderate scores on the seale, 4.6 percent ‘were sexually compulsive, and 1 percent were cybersex come pulses. People in the eybersex compulsive group reported spending 15 to 25 hours per week in online sexual pursuits, ‘Twenty-one percent of the respondents reported that their online activities had jeopardized at least one atea of their life the most common being personal relationships. ‘The most common characterization of problematic Internet use involving sexually explicit materials is porn(og- raphy) addiction, A search for this term on Google returned 71 million hits, including popular media articles, ads for ‘eatment programs and centers, ‘Asphynophile: The procice of selfhelp and professional books, inducing in oneseifa state of oxygen | thousands of folk remedies, and eficioncy in arderto create sexual | top many porn sites to count. We discussed. the concept of sexual Addiction in the Milestones box carler inthe chapter, The concept arousal of to ennance exctoment ‘nd orgasm also called rate asphysation of addiction was developed to explain substance abuse ‘The craving for the substance and the inability to con: trol its use result from neurophysiological changes due to repeated use; such changes have been documented. ‘Advocates of the application of addiction to porn argue that repeated exposure to pornographic images has simi: lar or “parallel” effects, They point to some reported cases ‘here excessive use leads to impairment in occupational Cr personal functioning or relationships. They also point to cases where men with histories of excessive exposure experience erectile dysfunction as evidence of “addiction.” Cities respond that similar neurophysiological changes hhave not been documented in response to visual stimuli of any kind (Ley et al, 2014). Clearly various responses can become conditioned to viewing online porn (or any visual stimulus for that matter—see the chapter “Theoretical Per spectives on Sexuality"), Conditioning and the desire to experience sexual gratification may account for repeated activity. Whether the user really cannot control the behav- for is the key question. AS we pointed out earlier, addic- tion piévides a plausible reason (excuse?) for behavior that results in pressure ftom others to change. Note that the review of referrals for hypersexuality identified one group 1s “designated patients” people whose partners brought them in fr teatment for “addiction The research suggests high rates of cooccurrence with other disorders; people whose Internet use is problematic are more likely to be depressed (by standard measures), report sleep disturbances, and report alcohol and drug abuse. The ques tion is which came first: the Internet use, which then led to depression and substance abuse (because the Internet use was causing problems), or the depression and substance sbuse, which led to the person finding escape online? arte Sting Fe eT Other Sexual Variations (Other sexual variations seem to be rare and have not been the subject of much research. Participation in them, how- ‘ever, may be fatal (asphyxiophilia) ora erime (zoophilia, frotteurism) Asphyxiophilia, or erotic asphyxiation. isthe practice ‘of inducing in oneselfa stateof oxygen deficiency inorder to create sexual arousal or to enhance sexual excitement and orgasm (Zaviaci¢, 1994), A variety of techniques, are used, including temporary strangulation by a rope around the neck, a pillow against the face, or a plastic bag over the head or upper body. Obviously, this is very ‘dangerous behavior; a miscalculation can lead to death‘In fact, it is estimated that it causes between 250 and 1,000 deaths per year in the United States (Innala & Ernulf, 1989). The average age of males who die during this activity is 26, leading investigators to suggest that it may be novices who die, due to their inexperience (Lowery & Wetli, 1982) Little is known about asphyxiophilia, Most of the ‘deaths atributed to the practice involve men, Such cases. are often obvious to the trained investigator. Characteris- ties that distinguish these deaths from intentional suicides include a male who is nude, crossdressed, or dressed with genitals exposed, and evidence of sexual activity at the time of death (Hucker & Blanchard, 1992). Pornog- raphy or other props such as mirrors are often present (Zavineis, 1994), Some cases involving women have been identified (Byard et al, 1993). A review of eight fatal cases among women found that only one involved unusual clothing and none involved pornography or props. Two of the cases were initially ruled homicide, one suicide, and five acci- dental death. The investigators suggest that death due to asphyxiophilia may be much more common among women than we realize, because these deaths are less often recognized for what they are by investigators. People engage in asphyxiophilia in the belief that arousal and orgasm are intensified by reduced oxygen. There is no way to determine whether this is true. If the experience is more intense, it may be due to height ‘ened arousal created by the risk rather than by reduced ‘oxygen, Some believe that certain women may experi fence an orgasm accompanied by urethral ejaculation; this belie has been identified as one reason women engage in asphyxiophilia. Again, there is no evidence. ‘An online survey collected data from practitioners. Seventy-one percent reported masochistic activities, ‘and 31 percent sadistic ones. Sixty.six percent reported using bondage, and 14 percent reported using electr- cal stimulation. Fortyone percent engaged in it alone (Hucker, 2008), ‘Zoophiliais sexual contact with an animal; this behav- jor is also called bestiality or sodomy; although the lat ter term is also used to refer to anal intercourse or even ‘mouth-genital sex between humans. About 8 percent of the males in Kinsey’s sample reported having had sex tual experiences with animals. Most of this activity was concentrated in adolescence and probably reflected the experimentation and diffuse sexual urges of that period. [Not surprisingly, the percentage was considerably higher among boys on farms; 17 percent of boys raised on farms ‘had had animal contaets resulting in ongasm. Kinsey found that only about 3 to 4 percent ofall females have had some sexual contact with animals. Contemporary therapists report eases of men and women engaging in sexual activity with household pets. Activities include masturbating the animal, oral-genital contact, and intercourse. Researchers recruited participants through a network ‘of people with sexual interests in animals (Williams & Weinberg. 2003). Data were obtained from 114 men, all White, with a median age of 27; 64 percent were single, never married. Ninetyhree percent defined themselves as “zoophiles” and said this identity involved a concern for the anima’s welfare and an emphasis on consensual sexual activity. They viewed themselves as better than “bestia ists,” who they said were not concerned about an animal's welire, Given a list of possible reasons for sexual inter est in animals, the two most common were a desire for affection and pleasurable sex. The type of sexual contact reported by the men varied by the type of animal. Receiv ing oral sex und receiving anal intercourse were the most frequent activities with dogs, whereas performing vaginal and anal intercourse were most frequent with horses. Only ‘one man preferred sheep Many ofthe men had not had a ‘human partner in the preceding year. The researchers sug: est that a preference for sexual activity with animals can be explainedby learning theory in that the rewards offered by sex with dnimals are immediate, easy, and intense, and thus extremely reinforcing. They suggest that the respon- dents’ choice of animal is explained by their earlier condi tioning, most men preferring the type of animal they fist hhad sex with, Frotteurism is a paraphilia identified by the DSM. It is defined as sexual fantasies or behaviors involving touching or rubbing one’s genitals against the body of a snonconsenting person, usually in a crowded public place (Lussier & Piche, 2008). When the behavior is intense, causing clinically significant distress or impairment in functioning, it constitutes froteurstc disorder. Milder orms of this activity are common. A man may approach ‘a woman from the rear and press his penis against her buttocks, or a woman may approach a man from the side and rub hee genitals against his le or hip. The target may bbe unaware oft iit occurs in a crowded elevator or sub- ‘way train’ or in the crush ofa crowd at a sports event or ‘Trolism, or threesomes, refers to a sexual encounter involving three people. Toilism may reflect negotiated nonmonogamy (see the chapter “Sexuality and the Life Cycle: Adulthood”). It isa staple of erotic video and stories. In @ sample of young adults, 13 per- cent had engaged in a threesome "Ad there's relevant joke, What's the difeence between Mick Sager anda Scotsman? ‘Mick Jar sings, “Hy, you at off of my chou." The Scotsman says, "Hey. Mood, et off of my ewe” ver ridden the New York subway during rsh hou? Hyori ‘stars, i's dream come te! Joes involving touching or rubbing ‘one's genitals against the body ofa ‘nonconsenting peso. ‘Trolism (TROY-ubL- sm}: Three people having sex together oophile Sexual coract with an ana ‘also called bestioty or sodomy. Frotteurism: Deriving sexual satisfac: tion from fantasies, urges, or benav-354 Saliromania: A deste to damage or sola woman ar her clothes. coprophilia (e9p-0h-FILL-eo-uh) Deriving sexual satisfaction frm con tact with feces Necrophila: Sexuel contact witha dead person, Sexsomnia Refers to avtomati Unintentional sexual behaviors during sleep: elo called sleep sex and 64 percent expressed at least some interes in doing 0, although the level of interest was low (Thompson & Byers, 2017). Saliromania isa disorder found mainly in mena desire to damage or soil a woman or her clothes or the image of ‘@ woman, such as a painting or statue, The man becomes sexually excited and may ejaculate during the act Coprophilia and urophilia are both variations having to do with excretion, In coprophilia the feces are important to sexual satisfaction, In urophilia i isthe urine that is important. The urophiliae may want to be urinated on as part of the sexual act. Insiders refer to urination as a “golden shower" or “water sports” [Necrophiia is sexual contact with a dead person. Like ‘most sexual variations, it ean range from mild to severe. In the mild cases, the person may just fantasize about sexual Intercourse with a dead person (Agerawal, 2008). In the more serious cases, the person actually engages in sexual intereourse with a dead body. In extreme cases the homicidal necrophiliac kills @ person and then has sex withthe corps. ‘Sexsomnia, or sleep sex, refers to automatic, unin- tentional sexual behaviors during sleep (Williams & Lettieri, 2012); the term was introduced in 2003 (Shapiro et al., 2003). The behavior occurs during honrapid eye movement sleep. usually in the first hours of sleep, and is related to an abnormal transition between sleep and wake states. It typically arises from slow-wave sleep, which is characterized by reduced cortical control by the brain leading to uninhibited ‘behavior. The person is unaware of the behavior or their surroundings, and if awakened has no memory of what happened. The range of reported sexual behaviors is broad, from sexual sounds like moaning, to fondling. mastur bation, cunnilingus, sexual intercourse with or with ‘out orgasm, and sexual assault (Sehenck et al, 2007). About 80 percent of the reported cases involve men. Partnered behaviors typically involve another person in the same bed, Partners may experience physical inj ries, Both the actor and the partner report various neg- ative psychosocial aftereffects, including guilt, shame, embarrassment, alarm, and low selfesteem. Sexsomnia obviously may cause relationship problems. Sexsomnia thas features in common with other sleep somnias (sleep- walking, sleep eating); the dis. tinguishing feature is persistent sexual arousal-erection, lubrica tion, orgasm-during the episode Causes oF contributing fee- tures include things that can di ‘upt normal sleep eyecies, such as sleep apnea, sleep deprivation, stress, alcohol use or abuse, and ‘some medications, Sexsomnia is considered a sleep disorder rather than a paraphilia, but some reported cases involve paraphilic behavior (¢. genital fondling of a minor). eee eed Prevention of Sexual Variations For many of the variations discussed inthis chapter, there ia continuum from normal to abnormal. People whose ‘behavior flls at the normal end enjoy these activities at ‘no expense to self or others. People whose behavior falls atthe abnormal end are cause for concern. ‘The misery that many people suffer—for example, the sex ually compulsive porn user-not to mention the harm they ‘may do to others (eg. the child molester), is good reason {to want to develop programs for preventing these kinds of sexual variations (Qualls etal, 1978). In preventive medi- cine, a distnetion is made between primary prevention and secondary prevention. Applied to the sewal variations that ge tothe abnormal level (I's cll these problematic sexual variations), primary prevention would mean intervening in home life or in other fictors during childhood to help pre- vent problems from developing or trying o teach people how to.cope wit erses or stress so that problems do not develop. In secondary prevention, the idea is to diagnose and treat the problem as early as possible once it has arisen, so that lficuties are minimized, It would be highly advantageous to do primary pre- vention of problematic sexual variations~that is, to head them off before they even develop. Unfortunately, this is proving to be difficult, fora number of reasons. One prob- lem is the diagnostic categories. The categories for the diagnosis of sexual variations are not nearly as clear-cut in real life as they may seem in this chapter, and multiple diagnoses for one person ate not uncommon. That i, a given person might have engaged in incest, pedophilia, and exhibitionism, IVit i unclear how to diagnose sexual variations, it is going to be rather difficult to figure out how to prevent them. Further muddying the waters is the occurrence of paraphilias and other psychiatric cond tions. A study of men with paraphilie disorders systema ically assessed co-occurrence (Katka & Hennen, 2002). More than two-thirds had mood disorders (39 percent diagnosed with major depression), 38 percent had anx- iety disorders, and 34 percent abused psychoactive sub- stances. Men with paraphilias were significantly more likely to abuse cocaine. One-third of the men had ret rospectively diagnosed attentiondeficit hyperactivity disorder. ‘An alternative approach that seems promising—rather ‘than figuring out ways to prevent each separate variation—is to analyze the components of sexual development. Distur- bance in one or more of these components in development ‘might lead to different sexual variations. Two componentsFigure 7 Advertsing for partners. Many websites and magazines cary “personel ads.” ‘Panther Media Gmbt/Aamy are sexual responsiveness (arousal to appropriate or Inappropriate stimulf) and formation of relationships with ‘others (Baneron, 1978. It seems clear that diferent developmental compo- nents are disturbed in diferent variations. In the fetishist, it is the second component, sexual respon- siveness to appropriate stimuli, that is disturbed, And in the case of the exhibitionist, it may be that the ability to ‘orm relationships is disturbed. The idea would then be to try to ensure that as chil dren grow up their development in each of these com- ponents is healthy. Ideally, sexual variations should not ‘occur then, tis clear that childhood sexual abuse i risk factor for paraphilic behavior and paraphilic disorders later in lie Because adults are responsible for sexual violence against children, prevention (and treatment) must be targeted. at adults. One program whose suecess has been documented js Stop It Now!, a community-based campaign (Laws, 2008), It involves media eampaigns to educate the public and change policy. The project began by collecting survey and focus group research on knowledge and awareness in the community. Then it conducted a social marketing cam Paign designed to increase public awareness and impact abusive behavior. The campaign used multiple media, including radio, cable and network TV, newspapers, adver- tisng in buses, and an interactive website. It established a toll help line to enable offenders to receive informa- tion and a referal to a clinician if desired. An evaluation the case of Indicated that abusers called for help: 118 people volun- tarily sought assistance, and another 25 turned themselves into the legal system. The program undoubtedly prevented ‘many children from being sexually abused SE ETT Treatment of Sexual Variations Some of the sexual variations discussed in this chapter, such as the mild fetishes, regular masturbation, or view: ing erotic materials, are well within the normal range of sexual expression. There is no need for treatment, Others, however, fall into the abnormal range, causing personal anguish to the individual and possibly harming unwilling victims. Treatments are needed for these problematic va ations, particularly those that are paraphilie disorders as defined by the DSM. Various types of treatments have ‘been tried, each based on a different theory of the causes ‘of sexual variations. We now look at four eategories of ‘treatments: medical treatments, cognitive behavioral ther pies, skils training, and AAAtype I2step programs. We also review research on the effectiveness of each, Medical Treatments. Inspired by the notion that sexual variations are caused by biological factors, various medical treatments for sexe ual variations have been tried over more than a century356 Some of them look today like nothing other than crue and unusual punishment. Nonetheless, people would love to have a pill that would cure some of these complex and painful or dangerous paraphilic disorders, so the search for such treatments continues. Surgical castration was used fairly commonly in the United States in the 1800s and early 1900s as a treat- ment for various kinds of uncontrollable sexual urges (Bullough, 1976). The idea resurfaced in recent years in some court cases in which eastration was proposed sa treatment for rapists, as discussed in Sex Offenders— Castration or Incarceration? in the chapter “Sexual Arousal.” Such treatments are based on the notion that removing a man’s testosterone by removing the testes will lead to a drastic reduction in sex drive, which will in turn erase urges to commit sex offenses, However, as wwe saw in the chapter “Sexual Arousal,” a reduction in testosterone levels in humans does not always lead to a reduction in sexual behavior, Surgical castration cannot bbe recommended as a treatment for sex offenders either ‘on humanitarian grounds or on grounds of effectiveness. Hormonal rreaiment involves the use of deugs to reduce sexual desire, based on the assumption that sexual arousabi- ‘ty is dependent on maintaining the kvel of androgen in the body above a given threshold. Several drugs have been tried in the past SO years. These drug treatments have typically been used with adult male offenders who are arrested for sexual contacts with children or exhibitionism. The drug _mediroxyprogesterone acetate (MPA), which binds to andro- ‘gen receptors, vas commonly used in the United States for some years. However. the drug has serious, adverse side effects, and its use has been discontinued in Europe (Thibaut et al, 2010). Moreover, limited evidence suggests it did not reduce the likelihood of reoffending. Cyproverone ‘acetate (CPA) is replacing MPA; it acts as both progestin and an antiandrogen. 1 binds to all androgen receptors, ‘neluding those inthe brain, and blocks testosterone uptake. Itis taken daily as a tablet or injected weekly or biweekly Clinicians also use leuprolide acetate (LA), a synthetic analog of gonadotropin releasing hormone (GnRH; see the chapter “Sex Hormones, Sexual Differentiation, and the ‘Menstrual Cycle"). These drugs are also called LHRH ago- nists. A systematic review concluded that these drugs are eifective in the treatment of paraphilic disorders and are ore effective than other drugs (Turner & Briken, 2018), The use ofan alternative, pschopharmacological teat ‘ment, is based on the idea that people with problematic paraphilias are often suffering from psychological prob- Jems such as depression and that treating the depression ‘will take care of the paraphilic behavior. Here, psychotro- pic medications, like antidepressants such as Prozac, are ‘administered to offenders. These medications influence patients’ psychological functioning and behavior by their faction on the central nervous system. Antidepressants are being used with paraphilies who are also diagnosed ‘with obsessive-compulsive disorder or depression. These, drugs appear to change the obsessive compulsive behavior rather than sexual desi (Gijs & Gooren, 1996). There is ‘great deal of interest in the use of the antidepressants, knoven as selective serotonin reuptake inhibitors (SSRIS). ‘These drugs also have been successfully used to treat ‘compulsive behaviors. Their suecess with people exhibit- ing paraphilic disorders is consistent with the idea that these conditions are a type of obsessive-compulsive disor der (Miner & Coleman, 2001). A review of effectiveness research suggests that SSRIs may be most effective with juvenile offenders (Thibaut eta, 2010), Both hormonal and psychopharmacologial treatment should be used as only one element in a complete pro- gram of therapy, which should include counseling and ‘treatment for other emotional and social deficits (Saleh & Berlin, 2003). The best results are obtained with people who are highly motivated to change their behavior and therefore comply with the prescribed treatment regimen. If the patient stops taking the drug or participating in other apeets of treatment, the program will fai. Unfortu nately, one ofthe limitations of research on the effective. ness of these treatments is the high dropout rate Cognitive Behavioral Therapies Some treatment programs are based on cognitive behav ‘oral therapies (CBT). Comprehensive programs include elements sueh as the following (Grubbs et al, 2015: Hallberg et al 2017) 1. Education on the person’s condition and factors that can contribute to the continuation of the behavior, such as clasical and operant conditioning, 2. Practice in impulsecontrol skills and_ mindfulness (Giscussed in the chapter “Sexual Disorders and Sex Therapy”). 3. Training in problemsolving skills ifthe person experi ences depression, anxiety, or boredom. 4. Cognitive restructuring (modifications. of distorted thinking) to help the person deal with negative thoughts. 5. Skills to prevent relapse. Convicted offenders sent to correctional facilities are likely tobe treated with programs of this type, i'they receive ny treatment. An evaluation ofthe effectiveness of programs for adult offenders reports that highquality CBT programs for sex offenders in prison reduced recidivism 15 percent and for offenders on probation the reduction was 31 percent (Aos eal, 2006). Note that many people do not reoffend fol lowing release. Ifthe rate of reofense for unteated people is 30 percent, a 15 percent reduction would be about 5 people per 100 released offenders. The Regional Treatment Centre sa secure, prisor-based treatment facility in Canada; it pro- Vides high-risk offenders with an individualized, CBT-basedprogram targeting criminal thinking patterns, criminal asso- ity. Offenders are typically people diagnosed with paraphilie bitionism, and sexual adism. The program typically lasts 7 followed for 1wo 14 people) ‘months, About 250 released offenders were and one halt years poste ase; only 5.5 percent reoTended in that period (Wikson et a, 2013), A meta-analysis found that recidivism rates for women convicted of sexual offenses (only some of which were paraphilic) were much lower than rates for men (Cortoni eval, 2010), We noted earlier the younger age of some sex offend: rs in the United States. A therapeutic program targeting young sex offenders using CBT and skill traning been shown to be effective (LeTourneau etal, 2009). The program, Muliystemic Therary (MST), involves fail therapy, behavioral parent (skills) traning, and CBT. The intervention is individualized to the specific offender and their caregivers and is presented in home and school. I addresses youth and caregiver denial about the offense minimizing the youth's access to potential vietims, and Promoting age-appropriate and normative social exper ences with peers. Youth (median age 14, all but 3 male) ed to MST oF the usual treatment nile offenders in that jurisdiction, one prescribed for juv weekly group treatment session following a standard pro- tocol, At 12-month followup, youth in MST showed signif icant reductions in problemati sexual behavior (77 percen vs. zero decline), delinquency (60 percent vs, 18 percent) and substance abuse (50 percent vs. 65 per * A review of literature on treatment of sex offenders reports that such programs are more effective with juveniles than adults, and mos effective with high-risk juvenile offenders, those with prior arrests (Ward etal, 2008), Skills Training According to yet another theoretical understanding, peo- in thei behavior because the ple with paraphilias eng have great difficulty forming relationships, and so they do rot have access to appropriate forms of sexual gratfica tion. This perspective is consistent with data on 1Q differ Jers and controls. A metaanalysis ences between sex offen of 75 studies found that adult males who commited sex significantly lower on 1Q tests than nonof fenders, and lower than those who committed nonsexual es (Cantor et al, 2005). Among sex offenders, the younger the age of the vietims, the lower the IQ score of the offende Mi: ‘and maintain conversation. They may fd it difficult 10 hese people do not have the skills 10 initiate dehelop intimacy (see the chapter “Attraction, Love, and Communication”) (Keenan & Ward, 2000), Such people may benefit from a treatment program that includes social skills training. Th training may include how to carry on & 2 appro- prigely assertive, and identifying irrational fears that are inhibiting the person (Abel eta, 1992), These Figure 8 Tiger Woods, who was linked in med reports with at least 1 him, entered 357 men, several of them claiming long-term affairs w treatment for sex addiction in 2010, Ee Gay Poet Io358 Figure 9 The centerpiece of 12-step programs such as Sex Addicts Anonymous is group meetings in which participants confront their addiction with the support of other group members. [Davi Harry Stowar/ Ge Images AA-Type 12-Step Programs AAs we saw in Milestones in Sex Research: Sexual Adde- tions, sexual addiction theory argues that many people who engage in uncontrollable, inappropriate sexual pate teens are acted to their particular sexual practice, The appropriate treatment, according to this approach, i one of the 12step programs modeled on Alcoholics Anonymous Treatment programs based on this upproach have become very common in the past 30 years. Tey include Sex Addicts Anonymous (SAA), Sex and Love Addicts Anonymous (SLAA), and Sex Compulsves Anonymous These programs are run by group members and are genet ally free to participants. Most ofthe ecovery or “rehab centers in the United States utilize groups based on AA principles, led by a professional staff member, s the core of their programs. These centers are « mut-bilin-do lar industry, and their use has entered everyday language: “going into rehab.” Twelvestep programs combine cog tive restructuring, obtaining support from other members ‘who have the stme or similar problem behaviors, and enhancing spirituality. Ths last aspect involves increasing one's awareness ofa “higher power” who can be relied on to help one recover, Given their popularity, the obvious question is whether they are effective. AA-Ased groups in the community are generally unwilling to cooperate with researcher, believing that to do so would prevent group members ffom concentrating on recovery. AS a result little research data exist on these programs. One recent study of 12step treatment for compulsive sexual behavior did find it to be effective (Efrati & Gola, 2018), What Works? Mete-analyses ofthe effectiveness of treatment programs for sex offenders consistently find that some types of programs are more effective than others. Typically the treatment is given to a mixed group of sex offenders, including paraphilics, rapists, and child sexual abusers AA systematic review of controlled outcome evaluations ‘of psychosocial and hormonal treatment programs found that, overall, sueh programs reduced sexual recidivism bby 37 percent, compared to those in control. groups (Schmucker & Losel, 2008). A review of all types of treat ‘ment programs concluded that only CBT-based programs are consistently shown to be effective (Thibaut et al. 2010), Among programs treating incarcerated offenders, the rate of reoffending 20 years following treatment is estimated at 27 percent. As noted earlier, the inte ‘multifocal program of the Regional Treatment Centre in Canada reported a reoffending rate of 5.5 percent 2.5 years following treatment, Programs are also more elfective with some types of offenders than others. The programs have the largest effect with rapist, the second largest with exhibitionists, and the smallest significant effect with inteufamily child sex offenders.‘ment to the individual. of such behaviors, communities. teacher who has sex wi but should not be categorized as a pedophile Using diagnostic labels accurately In this chapter, we discuss sexual behaviors that depart from the norm in U.S. society. To bring some clarity and structure to the discussion, we rely on the Diagnostic and Staustcal Manat elassification system. It identifies {number of paraphilias, which are intense and persistent atypical sexual interests. Paraphilias are distinet from paraphilicdsonders, which are paraphilias that are recurrent, last atleast 6 months, and ereate distress or impair ‘A highly publicized paraphilia in North America is pedophilic disorder, in which the object ofthe recurrent, intense, sexually arousing fantasies, urges, or sexual behaviors are prepubescent children (generally under 13 years tf age), Media frequently report that authorities are looking for or have arrested someone fo (attempted) sexual contact with a 9-or I1-or [3 yearld youth. Many people i pedophile, is mentally il and should be imprisoned or hospitalized for life. The application ofthis diagnostic le! ‘h more likely if there are reports that the person has engaged in similar activity in the past—that is, “has a history” immediately jump to the conclusion that the person is @ “A search of the law enforcement and clinical literature will quickly reveal that many different kinds of people engage in sexual contact with children or adolescents, and many do not fi the DSM criteria, For example, there are humerous eases of schoolteachers engaging in sexual activity with 15-or 16yearold students, but that does not tthe “efinition of pedophilia because the students are not prepubescent children. (Note that we are not saying that suc Dehaviors between students and teachers are aeceptable—just that it isnot correct to call sucha teacher a pedophile.) Critical thinking means that we must think carefully before we apply such labels to people. Often, we don think critically, we infer from publicity about one incident that the person is a pedophile, “chil-molester,” oF a “mor ‘Ster” The media often contribute by uncrtieally applying the abel, or repeating hearsay about the person's past ‘Applying the label can lead to tremendous hostility directed at the suspect, and even vigilante groups and death threats, often before a thorough investigation has been conducted. These incidents can ruin lives and devastate ‘Of course, perpetrators of violence or sexual violence toward children (or anyone else) need to be dealt with appropriately. What should be done needs to be determined by careful investigation of what happened, the perpe- trator’ cireumstances, and the perpetrators history. Some individuals truly are characterized by pedophile disor der, wth long histories of sexual contact exclusively with children of a particular age and gender, and an contol their behavior. They fit the diagnosis and should be treated accordingly. On the other hand, the 23,yearold ‘consenting I6yearold deserves discipline for inappropriate behavior with a student, to _——————_—_—_— SUMMARY When Is Sexual Behavior Abnormal? 1 seems reasonable to define abnormal sexual behavior as behavior that creates significant psychological distress for the person, impairs ther functioning in other areas of lie, ‘or harms others. The American Psychiatric Association defines a paraphilia as an intense and persistent atypical sexual interest. Paraphilias are distinet from paraphilc disorders, which are pacaphilias that are recurrent, last at least 6 months, and create distress or impairment to the individual “There is a continuum between normal and abnormal sexual behavior. Fetishism [A fetshist is @ person who becomes erotically attached to some object other than another human being. Most likely, fetishism arses from conditioning, and the range of. ‘behaviors involved provides a good example ofthe eontin- tuum from normal to abnormal behavior. 359360 Cross-Dressing : ‘Tere are multiple types of crossdressing, including trans women, dra, female impersonators and transvestites. Sadism and Masochism ‘Three styles of sexual interaction involve differences incon trol over sexual interactions. Dominance and submission involve a consensual exchange of power, and the enacting of| scripted performances. Bondage and discipline involve the use of physical restraints or verbal commands by one person o control the other. Bath D'S and B-D may occur without ‘genital contact or orgasm. Sadism and masochism involve ‘deriving sexual gratification from giving and receiving pain, Voyeurism and Exhibitionism ‘The voyeur is sexually aroused by looking at nonconsent: ing people who are nude, undressing, or engaging in sex ual activity. The exhibitionist displays their sex organs to ‘others. Both are generally harmless. Hypersexuality and Asexuality [Nymphomania and satyrasis are terms used to describe ‘women and men with an extraordinarily high sex drive Both terms are ambiguous and subjet to misuse. The term fypersexuality is potentially more precise, particu. lasy i tis defined behavioral Asenualt is defined as having no sexual attractions In surveys, asexuls report less sexual behavior, but they may ‘be sexually active ad in cohabiting or marital eationships. ‘They do not necessarily report suifering from distress. Cybersex Use and Abuse Use of the Internet to access sexually oriented materials fr people may become compulsive. The Internet may facilitate compulsion because ofthe three A's-anonymity, accessibility, and affordability. Onesifth of those respond: ing to online surveys report that their online activities have jeopardized atleast one area oftheir ives, most com- ‘monly personal relationships. Other Sexual Variations Other variations include asphyxiophilia, use of oxygen {eprivation in an attempt to enhance sexual sensations, and zoophilia, sexual contact with animals. Others include frotteurism and necrophilia, Prevention of Sexual Variations Programs that may prevent sexual variations are being developed and evaluated, One is Stop It Now!, « commu: niy-based program that has been shown to be effective in preventing child sexual abuse, Treatment of Sexual Variations Available treatment programs include medical and hor ‘onal treatments, cognitive behavioral therapy, skis training, and AAAype 12-slep programs. Each form of treatment may help some individuals whose sexual behay- iors are problematic, but only CBT-based programs are ‘consistently shown to reduce the frequency ofthe behavior ‘or reffending eet eee ne ir remem en nernne seen SUGGESTIONS FOR FURTHER READING Carnes, Patrick. (2012). Out of the shadows. 3d ed Center City, MN: Hazelden. This isthe classic statement by Carnes ofthe theory that various forms of sexual behavior can become addictions, ‘comparable to drug addiction, withthe same characteristics and responsive to similar kinds of treatment. Laws, D. Richard, & O'Donohue, William (Eds. (2008), Sexual deviance: Theory, assessment. and treatment. 2nd ed, New York: Guilford, This book has two well-researched chapters on each of the nine paraphilias, and several other variations. One explores psychopathology and theory, and the other explores assessment and treatment. ‘Lindemann, Danielle. (2012). Dominatrix: Gender crricism, and contol in the dungeon. Chicago: University of Chieago Press. This book presents & sociological approach to the work of the profesional dominatrix in BDSM culture. Design Elements: A Sexually Diverse Wortd icon (hands); ©Shuttestock/Dragon Images; Fist Person icon (people with arms crossed): Image Source Getty Images; Milestones in Sex Research icon (survey): ©Revi Tahilramani/Getty Images